Inspection on 25/03/09 for Dagenham Road

This inspection was carried out on 25th March 2009.

CSCI found this care home to be providing an Excellent service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dagenham Road 03/04/07

Dagenham Road 10/01/06

Dagenham Road 28/06/05

Dagenham Road 10/03/05

Dagenham Road 07/09/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Dagenham Road 357A-359 Dagenham Road Romford Essex RM7 0XX     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sandra Parnell-Hopkinson     Date: 2 5 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Dagenham Road 357A-359 Dagenham Road Romford Essex RM7 0XX 02085955336 02089848989 pauline@outlookcare.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Outlook Care care home 8 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 8 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD Date of last inspection Brief description of the care home The home is situated in Dagenham Road, with easy access, by bus to Romford town centre or Dagenham Heathway. The home has two units of four beds each. There are places for 8 adults with mental health support needs. The service user group at the time of inspection were semi-independent, needing prompting, reassurance and support from staff. The staff team work hard to ensure the service users independence is maintained, and liaise with other professionals to regulate service users health and Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 8 Brief description of the care home wellbeing. The home is staffed 24 hrs a day with a waking member of staff at night. Outlook Care provides the support whilst East Thames Housing Group is the landlord. Currently all of the beds are being purchased by the local PCT (primary care trust). A copy of the Statement of Purpose and Service User Guide are available in the home, together with a copy of the most recent inspection report. Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection undertaken on the 25th March 2009, commencing at 09.00 hours and finishing at 15.30 hours on the same day. Evidence was taken from the returned Annual Quality Assurance Assessment (AQAA), Annual Service Review, discussions with service users, the manager and staff, viewing records and other documentation including case tracking. A tour of the home was also undertaken. We would like to thank the residents and staff for their input and assistance during the inspection. Care Homes for Adults (18-65 years) Page 6 of 30 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 Care Homes for Adults (18-65 years) Page 7 of 30 7535. Care Homes for Adults (18-65 years) Page 8 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may use the service and their representatives have the information needed to choose a hope that will meet their needs. Evidence: From viewing files it was evident that comprehensive pre-admission assessment are undertaken prior to a resident moving into the home. Each resident has a service agreement/contract which clearly details the responsibilities and rights of both the provider and the individual resident, and agreements/contracts had been signed by both parties. It was apparent from talking to the manager that the service understands the importance of having sufficient information when choosing a care home, and a prospective service user visited the home during the inspection. Staff were observed to be welcoming and very helpful and able to answer questions which were being asked. There is a service user guide which is comprehensive and all residents are given a Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: copy of this document. Information can be provided in appropriate formats suited to the needs of the individual, as is other information which includes policies relevant to the service user. Admissions to the home only take place if the service is confident that staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Staff and existing residents are involved in the admission of a new resident. Care Homes for Adults (18-65 years) Page 11 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. Evidence: The key principle of the home is that people using the service retain control of their lives and that they direct the service. It was evident from discussions and observations that staff are fully committed in supporting individuals to lead purposeful and fulfilling lives as independently as possible. This does sometimes prove very difficult due to the lack of motivation displayed by some residents, but it does not prevent the staff team from continually trying to encourage and promote the principles of independence. Care plans are reasonably person centred and work is now commencing on a more flexible care plan format which will enable staff and residents to be more innovative around the development of his/her care plan. Equality and diversity issues are addressed in the care plans, and in discussions with staff at lunch time they Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: demonstrated a good understanding of the complexity of equality and diversity. The service operates a key worker system and there was evidence that care plans were being evaluated and regularly reviewed. A resident told us that she is actively involved in the development, evaluation and review of her care plan. Staff try to make the process interesting and use a variety of ways to help individuals to make a worthwhile contribution. Information includes risk assessment, how to keep safe, goals and aspirations, communication and choices. There is also comprehensive information on health needs. Through surveys and house meetings, the service ensures that residents are consulted regularly about their satisfaction with the home, and through this they are involved in the development of the service. Care Homes for Adults (18-65 years) Page 13 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are able to make choices about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities are available to meet the expectations of the individual service user. Evidence: It was evident that the service understands and actively promotes the importance of respecting the human rights of people using the service, with fairness, equality, dignity, respect and autonomy as being central to the care and support provided. Residents are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. However, some people require more motivation than others and staff continually try innovative activities to encourage motivation. Some residents attend college and 1 person is currently enjoying doing paper craft, needle craft and flower arranging, and another is learning computer skills. All residents have a holiday and Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: some go abroad with the support of care staff. From time to time the manager will hire a car and arrange trips out for residents according to their wishes. Residents visit the local shops independently, but where assistance is required a member of staff will accompany the person. Family links/friendships are encouraged and staff help to encourage and maintain these links. One resident visits her family at weekends and also is involved in family celebrations such as weddings. Residents are able to access all areas of the home independently, and were seen to be doing this during the inspection. All residents are encourage to make use of community facilities such as local colleges, supported employment schemes, pubs, restaurants and other leisure facilities. All residents have a freedom pass for travel on public transport, and some have membership of dial-a-ride or a taxi card. Residents are involved in cooking and menu planning, and then shopping for groceries. Fresh fruit and vegetables are always available and these were seen during the inspection. Where necessary meals are in accordance with an individuals religious and/or cultural needs. Residents told us that they have their main meal in the evening because this fits in with their daily activities and routines. Throughout the inspection residents were seen to be helping themselves to drinks and snacks and all have full access to the kitchen facilities. Care Homes for Adults (18-65 years) Page 15 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service can be sure that the health and personal care they receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Evidence: All residents have a care plan in place, but the format of these will be changing so that they are more person centred and will be produced in a format selected by the resident, and therefore, become a more flexible working document which will benefit both the resident and the staff. People told us that they receive personal and healthcare support which respected their rights to privacy, dignity and equality, and that they felt respected by the staff. Personal healthcare needs including specialist health needs, are detailed in the care plan, and a comprehensive overview of the health needs is given. Personal support is responsive to the varied and individual needs and preferences. The delivery of personal care is individual and is flexible, consistent, reliable and person centred. Staff are responsive to changing needs and choices. Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: All of the care and health plans examined clearly recorded referrals to specialist health care professionals, and also evidenced that appointments were being kept. Records indicated that residents attended routine health appointments including GP, dentist, chiropodist and routine cervical and breast screening. Residents are encouraged to make and keep their own appointments, but support is provided where necessary. Due to the mental health needs of the residents, staff work to clear and robust practices when caring for the residents, and this was evidenced in care plans and in discussions with staff. Clear information is contained within the care plans of the actions to be taken if the mental health needs change. Staff work to a high consistent standard to ensure that the residents receive the care and support necessary to enable them to live independent lives. Policies and procedures are in place for the receipt, handling, recording and disposal of medication. An audit was undertaken of the management of medicines in the home, and the medication administration records (MARS) were examined and found to be in order. Medication storage was satisfactory and regular audits are being undertaken and recorded by the manager to monitor and ensure compliance with the organisations policies and procedures. All staff involved in the administration of medication have received appropriate training, and within the organisation the manager is a medication champion who helps other services with medication issues. The service does have a policy and procedure around end of life issues, and it was evident that these are being discussed with some residents and families in a sensitive manner, and wishes are being recorded in care plans where appropriate. Care Homes for Adults (18-65 years) Page 17 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be confident that they can express their concerns, and have access to a robust, effective complaints procedure. Also that they will be protected from abuse and have their rights protected. Evidence: There are policies and procedures for dealing with complaints, and these are available to all residents in a format which they can understand. Residents confirmed to us that they knew how to complain and that they would speak to the manager, or their key worker or an advocate. One resident had made an appointment with an independent advocate who was visiting during our inspection. Again it was evident that formal written complaints are recorded, but we did not see evidence of verbal issues of dissatisfaction or concern being recorded. This was identified at the last key inspection and it is essential that such verbal concerns are also recorded so that the service can gain a clear, evidenced based, picture of improvements which need to be made to the service, or that have been made due to the positive listening to residents. Staff were aware of the policy and procedure on whistle blowing, and they also confirmed that they had received training in safeguarding and abuse awareness. This was also evidenced in training records. Staff also demonstrated actions that they would take if they had concerns about the welfare and safety of any of the residents. Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: Staff understood what restraint is and alternatives to its use in any form would always be looked for. During the inspection we observed that all residents are free to come and go from the home, but they are expected to let a member of staff know when they are leaving the home for safety and duty of care reasons. Since the last inspection there has been 1 safeguarding referral. This was due to the lack of support being given to the home and a resident by health care professionals. Eventually the matter was resolved but had the proper and timely support been given earlier by the health care professionals, it would have reduced the stress to both staff and the resident. Care Homes for Adults (18-65 years) Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables residents to live in a safe, generally well-maintained and comfortable environment which encourages independence. Evidence: We undertook a tour of the home during the inspection and found that all parts of the home, with the exception of 1 bathroom, were clean, well maintained and odour free. The communal lounge, kitchen/dining area in both units were well decorated and furnished in a homely manner. Bedrooms are furnished and decorated to suit the needs and preferences of each resident, and they are responsible for the cleaning of their own bedrooms. Staff will support in this where necessary. Each of the two units has its own utility room and again these were tidy and clean. The service employs a housekeeper on two days each week for the undertaking of heavier cleaning tasks. Since the last inspection the downstairs bathroom, identified in that report as needing attention, has been redecorated but the ongoing problem with damp has still not been resolved. There are black mould marks on the ceiling and there was also a strong and unpleasant odour in this bathroom. Although the building is owned by East Thames Housing Group, Outlook Care is the organisation registered with the Commission and is therefore responsible, under the Care Home Regulations, for the maintenance of the Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: premises in good order. The requirement made at the last inspection is again repeated as this long outstanding problem must be resolved for the benefit of the residents living in the home. Care Homes for Adults (18-65 years) Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be confident that the staff team is trained and in sufficient numbers to meet the individual assessed needs of the residents. Also that the staff team is committed and that the recruitment procedures within the service are robust to safeguard the residents. Evidence: The organisation has a highly developed recruitment procedure that is robust. We were told that people using the service are now being involved in the recruitment of new staff and will receive training and support to do this. The service has a small but very stable workforce and there has been no staff turnover since the last key inspection. Staff were observed to interact well, both with each other and the residents and effective team working was seen throughout the inspection. One member of staff told us that they really gel as a team, but still have differences of opinion from time to time but that these can be discussed openly. Current staff have been trained to NVQ level 3/4 and the manager has now achieved the Registered Managers Award. Training is given a high priority and all staff have Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: undertaken training in mental health. Staff were aware of the Mental Capacity Act 2005 and some have undertaken training. Staff also cover day and night duties and in this way they have gained an insight into the residents moods and needs both during the day and during the night. Staff told us that this aspect has really helped them to understand the residents over a 24 hour period. There are consistently sufficient staff available to meet the needs of the residents, and when necessary the manager will rota additional staff to be on duty. Training records showed that staff have undertaken training in the mandatory areas. All staff have in place a training and development plan, and this is discussed at the regular staff supervision sessions and monthly meetings. Records are being maintained of both supervision sessions and the monthly meetings. Training is undertaken both internally and with external trainers, and the manager has recently attended a conference arranged by Skills for Care. In discussions with staff they demonstrated a very good understanding and awareness of equality and diversity issues, and it was apparent from observations that this is being put into practice within the service. Residents told us that the staff team are approachable and that they can talk to them easily, and that they felt that their needs were being met. Care Homes for Adults (18-65 years) Page 23 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect, and has effective quality assurance systems. Evidence: Since the last key inspection the registered manager has now achieved the Registered Managers Award. She is highly competent to run the home and meets its stated aims and objectives. The manager demonstrated a sound knowledge of both strategic and financial planning and had a sound knowledge of the organisations strategic and financial planning systems and how the business plan for the home fitted with these. The manager was able to describe a clear vision of the home and it was evident that she communicated a clear sense of direction and was able to evidence a sound understanding and application of best practice particularly in relation to continuous improvement, customer satisfaction and quality assurance. Equality and diversity, human rights and person centred thinking are given a priority by the manager who was able to demonstrate a high level of understanding and best practice in these areas. Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: From observations and discussions with staff and residents, it was evident that the manager provided an excellent role model, and the manager is currently a medication champion within the organisation. The manager ensures that staff follow the policies and procedures of the organisation, and staff demonstrated an awareness of these during the inspection. The ethos of the home is open and transparent and the views of both the residents and staff are listened to and valued by the manager. The AQAA (annual quality assurance assessment) contained good information that was supported by appropriate evidence gathered during the inspection. The manager is aware of areas for improvement and is always working towards these. The service has efficient systems to ensure effective safeguarding and management of residents valuables. People are supported to manage their own money, but to this end the current financial policy of the organisation must be reviewed in line with the requirements of the Mental Capacity Act 2005. People deemed to have capacity should not need to have to get a senior manager to authorise expenditure of any item that they wish to purchase. What may be appropriate expenditure for one person may not be for another, but this does not mean that the person cannot purchase an item which may be considered inappropriate by another person. Of course the organisation has a duty of care, but this must be in line with legislation and the Mental Capacity Act 2005. To this end the organisation may need to review some of its policies and procedures. Maintenance records were viewed and these were up to date and in good order, and there was a written record of all safety checks. The home proactively monitors its health and safety performance and consults experts and specialist agencies as required. The home has achieved a 5 star rating from the local environmental health department. The manager and her staff team have a good understanding of risk assessment processes which is underpinned by promoting independence, choice and autonomy. These principles are taken into account in all aspects of the running of the service. The organisation undertakes the necessary monthly visits required under Regulation 26 of the Care Homes Regulations, and copies of these reports are kept in the home. When necessary the home notifies us of issues as required under Regulation 37 of the Care Home Regulations. Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: Care Homes for Adults (18-65 years) Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 41 24 The registered persons must 30/04/2009 ensure that its systems for evaluating the quality of the service is regularly reviewed in line with new legislation. The introduction of the Mental Capacity Act 2005 will impact on some of the policies and procedures, with particular reference in this instance to finances. All policies which may be affected by the MCA must be reviewed to the benefit of residents. 2 42 23 The registered persons must 29/05/2009 ensure that all parts of the home, both internally and externally, are maintained so as to promote and protect the health, safety and welfare of residents. Although the downstairs bathroom has been redecorated, the promblem Care Homes for Adults (18-65 years) Page 28 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action of the damp has still not been resolved. This must be done in the interests of the residents. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!